20553 APPLICANT TO FILL IN INFORMATION WITHIN RED LINES — USE BALL POINT PEN ONLY
Buildl men lJemlfiotlan Ahniils' / - - PERMIT NO.
Bu1116ng Address: ,• f�� ` r 4"d1— ,--6=111,f 111A_ 20553
nerr9 a ` ane:
A
11 CITYOFCUPERTINO-BUILDING DIVISION I—,
d "• ) L NAPPLICATION I PERMIT
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p P Va: BUILDINGF].FLTRICA4PLUMBINGMECHAMCAL CATEGORY CONTROL M
Amhlted/Engineer. L c.Na
6 QTY ELECTRIC PERMIT FEE BUILDING PERMIT INFO
Address: PERMTISSUANCEF-1 1:1 ❑
LICF.NSEDCO TRACTOR'SDECLARATION•
I hereby affirm that l am Bernard under provisons of Chapter9(commere APPLIANCESRESIDENTIAL ]OB DFSCKIPHON
Ingwlthsec n7OM)ot DiNsim3ofthe BuMn and PmfeaslonsCodgandm
I icense is In fun PANELS
k.
License la LYfen.
Date Contnctor��`r? Q (� - UPT02DOAMPSS• �/�
ARCHITECT'S DECLARATION 701-1000 AMPS v �.
be CO Iunderstand my plans shag be used as public records. OVER1000AMPS SQ.FT.FLOOR AREA $/SQ.FT.
k () Licensed Professional SIGNS ELEC L '
<<In]LG7u OWNER-BUILDER DECLARATION SI'ECIALCEiCUI LSC
Z[- Ihereby afflrmthat l am exempt from,the Contractor's License law for the
pp following reason.(Section 70315,Business and Profealons Code:Any city or
contywhic mquimsapermittommtmd,alteglmpnave,demalbhorrepalr TEMP.M Oft INST.
any stmnum prior to Its Issuance,also requbea the appBont for such permit to
yy Q POWER D
tC t) thea signed statement that he Is r 9(ccud pursuant to the tion 700D)of
of the
Cortsic.3 fthe usi..License law(Chapter Ced mencing withSection and SWIMMING CTRI ��UATLON
I„�OS elon3otthe Buelnessand ProfesslomCode)orthathels exempttberefromand a
Qu the basis for the alleged exemption. Any violation of Section 70315 by any OUT1,FTS_SWrTyFIKZk
CM?V epplicantfor a permit subjects theapplicanl too civil penalty of not more than
tiv�undred dollars RESID LEL SQX.T. RIES TYPECONSIRUCTION
�n I,as
owner of the property,or my employees with wages as their sole
compensation,will do the work,and the structure isnot intended or offered for
O sale(Sec.70K Business and Professions Code:The Contradofe Llceme Law
$ does not apply to an owner of property who Wilds or improvesthereory and VJ OCC.GROUP RES.UMTS
EE whodoessuch workhlmselforthmugh Nsownemployeesprovided thatsuch
Improvements are not intended oroffered for sale.If,howevegthe building or T
Impmvemeni bmld withlnoneyearafcompletloo,theawner-W Bderwillhave -
tll,kurden of proving that he did not Wild orlmprove for purpmeofsale.). QTy, PL BIN PER FEE FLOOD ZONE ApN
(J Las owner of the property,am exclusively contiading with licensed PERMrr I CE
conlmdors to construct the project(Sec.7044,Business and Profession Code:
The Contractor'.License Law does nor apply to an owner of property who ALTER-DRAIN& -WATER(FA)
Wilds or Improves thereon,and who rontnda for such p(ujeda with.
ro�actor(s)II...d pursuant to the Contractor'.Limnx Law. FEE SUMMARY
I am vempl under Sec e k P C for this recon BACKFLOW PRO T.DEVICEouTSInvFEES
DRAINS FLOOR ROOF,AREA,COND. SANITARY Y_ N_
Owner Date RECEIPT Y
WORKMAN COMPENSATIONDECLARATION FIXTURES.I'FR TRAP SCHOOL TAX Y_ N_
Of hereby alfirm that I have a cerd(bate of Consent to seE-Insure,ora RECE NY
mnifimteofWorken Compematlanimunnmoramnilledmpythemof(See. GAS FA.SYSTEM-1 INCA OUTLETS PARK FEE Y N
3800,Tab Cd RECEB NY
Po11ryY GAS EA.SYSTEM-OVERY(F.A)
Com BUILDING DIVISION FEES
Opcedi(ied copy b
OCcrtlBed copy bfiled withh the
hercbyte cicitye ty lmpMbn divlvlon. CREASE/INDU9M WASTE INTERCEPTOR PLANCHECK FEE `
CERTIFICATE OF EXEMPTION FROM WORKERS' GREASE TRAP PAID
COMPENSATION INSURANCE
(Thissectloncend natbecompleted lftheper it bferone hundred dollars SEW'FR-SANITARY-STORM FA.200IT. Date RCCeI t#
($100).,1..) WATER HEATER W/VENT/MXCTR ENERGY FEE Y N
I mnlfythat In the performance of the work forwhlch this permit is issued,
I•hall not employ any person In any runner m m to jye(}.m the WATER SYSTEM/TREATING PAID
Workers Com motion of California to �I�
�i O . :Applicant A-s,�/aLa _��.. Date Recei t#
Z s) NOTICE TO APPL ANT:ILafter making this Certificate of Exemption,you NEW RESIDENTIAL I'LMB.
HO old becomesubject to the Workers Compenadion provisions of the Labor TOTAL:
IA Code,you must forthwith comply with such provisions orthis permit shall be
W. deemed revoked. U D G FL' . neo
�' CONSTRUCTION LLNDINC AGENCY SEISMIC FEE r
tl Zuf. I hereby atfirmthat there b a comtmnion lending agency for the perform ELECTRIC FEE
7O anecofthework forwhich this permit b lsnred(Sm.3097,CIv.C.) TOTAL:
V [ender'.Name PLUMBING FEE
LL F U dce.Addm - QTY. MECHANICAL PERMIT FEE MECHANICAL FEE
O W
bmnlcedifythatlhavereadthbapplimtionand•tatethattheabovelnformatlon
fl enm
.l agree to comply with all city and untyordinanm and state laws PERMIT ISSUANCE FEES PAID:
} relatingt.Wilding constroction,and hereby authorize represntativesofthb
F N city to enter upon the above-mentioned property for inspection purposes. ALTER OR ADDTOMECH.
Z (We)agree to save,indemnify an d keep harmiess the City of Cu ped lno Date Recei t#
V aga1vt11abiliBes,lid g ts,costs and expenses which may in any way accrue AIR HANDLING UNIT(TO 10,000 CFM) SUBTOTAL:
aga Wt Bald ityin uence o(the grani�g of this Permit
/�9v AIR HANDLING UNIT(OVER IgOliflum) CONSTRUCTION TAX
slgnatu ll lit antradar (�— EXHAUST HOOD(W/DUCT) CONSTRUCTION TAX PAID:
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous HEATING UNIT(TO IO0,000 BTU) Date Recei t#
material as defined by the Cupertino Municipal Code,Chapter 9.11,and the
Flea lth and Safety Code Section 2SS32(a)'! HEATING UNIT(OVER 1(X),000 BTU) TOTAL:
O Y. rI No -
Wllitheapp)lmntor No
Wilding occupant use equiprcent or devices VENTILATION FAN(SINGLE RESID) ISSUANCE DATE
which emit hazardous air contaminants as defined by the Bay Area Air _
Quality Management District? BOILFR-COMP OHPOR 100,000 BTI) PAIL)
Yes ❑❑No
have read the hazamousmaterials requirements under Chapter 6.95 of BOILER-COMP(OVER 100,000 BTU) JUN
11 �9�S9r'�
the California Health k Sate Cade,Sections 8505,75533 and 25537.1 J
understand that 11 he building does not currently have a tenant,that It is my NEW RESIDENTIAL MECH. SQ.Fr
mporuibWty to notify the occupant of the mqulrements which most be met �s� .{p
prior tobsuance fri dificateaf0cat . City of Cupertinm
Ow oraut orimd agent Qiftc TOTAL: ISSUED BY: Lk sJ
OFFICE COPY